Neighborhood Health Plan Formulary (Commercial) — Outpatient Drug Formulary Coverage Criteria
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Defines the outpatient drug formulary, coverage rules, prior authorization, step therapy, exceptions, and processes for prescribers, pharmacists, and members under Neighborhood Health Plan of Rhode Island's Commercial pharmacy benefit.
No material clinical or coverage changes in this revision.
Formulary Coverage and Exclusions
Formulary coverage and exception criteria
Coverage and exceptions for outpatient formulary drugs are governed by the following conditions:
See Coverage Limitations
Exceptions eligible for Non-Formulary coverage
- Formulary products are contraindicated for the patient.
Prescriber documents contraindication
- The patient has failed an appropriate trial of formulary or related agents.
Prescriber documents prior therapy and failure
- Formulary choices are not suited for the patient's clinical need or their use would jeopardize patient safety (e.g., would provoke an underlying condition detrimental to care).
Prescriber documents rationale and safety concern
See Exception Process for required steps
The Formulary applies only to outpatient drugs provided to members. Excluded from coverage are: drug products used for cosmetic purposes, drug products determined to be experimental (including those used in an experimental or off‑label manner), and drug products that fail industry‑standard patient safety screens unless additional clinical information is provided by the prescriber.
Drug products used for cosmetic purposes and products determined to be experimental or used in an experimental/off‑label way are considered not covered / not medically necessary under the Formulary. The determination of whether a product or its use is experimental will be made by the PBM’s Pharmacy & Therapeutics Committee using current medical literature.
Prescriber and Pharmacy Requirements
Prior Authorization Required
Prior Authorization is required for drugs listed with the PA designation in the Formulary. When a member presents a prescription for a PA drug at a network pharmacy, coverage must be approved before the claim can be processed. Prior authorization requests are reviewed on the individual patient's clinical need and in accordance with criteria approved by the Pharmacy & Therapeutics (P&T) Committee.
- PA-coded drugs in the Formulary require prior authorization before coverage.
- Submit completed Prior Authorization requests by fax or phone using the contact details below.
- Each request is reviewed against P&T-approved criteria and the member's clinical record.
Step Therapy Requirements
Step Therapy (ST) requirements apply to drugs listed with the ST designation. Step Therapy requires that specified formulary alternatives be tried and documented as ineffective or intolerable before the requested (ST) medication will be covered. If the required formulary alternatives are inappropriate for the member (e.g., contraindication, intolerance, or other clinical reason), the prescriber may request a Step Therapy exception.
- ST-coded drugs require documented trials of the specified formulary alternative(s) prior to coverage of the requested agent.
- If a formulary alternative is contraindicated or has caused intolerance, document the clinical reason when requesting an exception.
- The exception process (see documentation callout) should be used to request coverage without meeting step requirements.
Required Documentation for Prior Authorization / Exception Requests
To request prior authorization or an exception (including Step Therapy exceptions or Non‑Formulary coverage), the prescriber must provide supporting clinical documentation demonstrating medical necessity. Required documentation includes relevant diagnoses, prior medication trials (drug name, dose, dates, and reason for failure or intolerance), clinical rationale for the requested agent, and any relevant laboratory or clinical test results.
- Documentation should include: diagnosis, prior drug trials with dates/doses and reason for discontinuation, and supporting clinical notes or test results.
- Fax completed Prior Authorization form and supporting documentation to Neighborhood Pharmacy Department: 1-866-423-0945.
- Or contact Neighborhood Pharmacy Department by phone at 1-401-427-8200 to initiate the request and provide required clinical information.
Denial Process and Notifications
If a request does not meet criteria for coverage, Neighborhood will issue an adverse determination. The prescriber and member will be notified in writing of the decision, the clinical rationale, applicable benefit or guideline references, and appeal rights. Reviewers (Medical Director or Physician Reviewer) will discuss denials with the prescribing practitioner when appropriate.
- Denials will include reason(s), supporting guidelines or protocols, and instructions for filing an appeal.
- Prescribers may be referred to the Neighborhood Medical Director or Physician Reviewer for further discussion of clinical rationale.
- Members may contact Customer Service to file an inquiry or complaint; standard response and appeal notification protocols apply.
Key Terms
Step Therapy Criteria
| Step | Requirement | Exception allowed |
|---|---|---|
| 1 | ||
| Must try specified formulary products (listed as formulary alternatives) prior to initiating the requested medication | ||
| Provider may request an exception if required formulary alternatives are inappropriate or the member cannot take them |
Formulary Quantity Limits
Formulary Governance
The Formulary is maintained and evaluated by the Pharmacy & Therapeutics (P&T) Committee. The Committee reviews drugs for safety, efficacy, effectiveness, duplication, cost, and any restrictions; determinations about whether a product or a use is experimental are made by the P&T Committee based on current medical literature.
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